Stroke or Stoned? The 3 AM Differential We All Hate

Cold Open

3 AM. We've been running a peri-arrest in bay 4 for forty minutes. Bay 6 is a chest pain rule-out who keeps trying to leave. And the charge nurse is at the door: "There's a young guy in triage. His roommate says he's acting weird. Slurring his words. He's awake. Walked in."

You know exactly which differential just exploded in your head.

The Case

• 24M, no medical history, no medications, no allergies
• Chief complaint: sudden-onset slurred speech, right-sided weakness, started ~45 min ago
• Vitals: BP 138/82, HR 96, RR 16, SpO2 99%, temp 37.0
• Exam: Awake, oriented to person only. Dysarthria. Right pronator drift. Right facial droop. No fasciculations, no signs of trauma. Pupils equal and reactive. No nystagmus.
• Roommate at bedside: "He had two beers. Maybe. He doesn't do anything else."

The Differential We Hated

Anyone working EM long enough has been burned both ways on this one:

1. Acute ischemic stroke — young, but it happens. Carotid dissection. Vertebral. Patent foramen ovale with paradoxical embolism. Vasculitis. Cocaine vasospasm.
2. Intoxication / overdose — synthetic cannabinoids ("spice"), GHB, MDMA, fentanyl-contaminated stimulants. The "he doesn't do that stuff" history is famously unreliable.
3. Hypoglycemia — always. Always.
4. Postictal Todd's paralysis — would the roommate have seen the seizure?
5. Conversion disorder / functional neurological symptom disorder — late-stage diagnosis only, never your first stop.
6. Hemiplegic migraine — family history is everything here.

What We Did

Glucose was 94. Naloxone 0.4 mg IV — no change. NIHSS was 6. We called stroke alert.

CT head: unremarkable. CTA head and neck: left vertebral artery dissection with downstream cerebellar infarct. He'd gone to a chiropractor two days earlier for neck pain after a snowboarding fall.

Tenecteplase given within 90 minutes of symptom onset. Admitted to the neuro ICU. Walked out of the hospital five days later with mild residual right-arm weakness.

Clinical Pearls

• Young stroke is not zebra-rare. It's roughly 10–15% of all strokes. Dissection is the leading mechanical cause.
• Mechanism matters. Cervical manipulation, sports trauma, even violent vomiting can dissect a vertebral.
• NIHSS first, history second. Don't let the social context (young, presumed intoxicated, friend group, bar district at 3 AM) talk you out of imaging.
• CTA is your friend. Plain CT will miss this. If your gestalt says stroke and the CT is clean, get the CTA.
• Anchor bias is the threat. "Young + slurred speech + 3 AM" is a setup. Treat it like a fire drill — run the protocol, then form opinions.

What We Got Wrong

We anchored on intoxication for the first ten minutes. The pupils-equal-and-reactive exam should have moved us off that anchor faster. Lesson: when the exam doesn't match your leading hypothesis, abandon the hypothesis, not the exam.

Resources

• Caplan LR. Dissections of brain-supplying arteries. Nat Clin Pract Neurol. 2008.
• AHA/ASA Guidelines for Early Management of Acute Ischemic Stroke (2019)

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